Consultation Request To Oregon Health & Science University Form
Download a blank fillable Consultation Request To Oregon Health & Science University Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Consultation Request To Oregon Health & Science University Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Oregon Health & Science University
Consultation Request to OHSU
3181 SW Sam Jackson Park Road
Portland, OR 97239-3098
Please provide the following so we can schedule an appointment:
Tel: 503 494-4567
Toll Free: 800 245-6478
Pertinent medical records
Demographic sheet
Insurance authorization (if required)
■
■
■
Fax: 503 346-6854
Fax this form and pertinent medical records to 503 346-6854.
Thank you for referring your patient to
Oregon Health & Science University.
Please indicate the specialty
to which you are referring your patient:
Patient Information
❑ Allergy and Immunology
Patient Name: _______________________________________________________________
M
F
■
■
❑ Arthritis and Rheumatology*
❑ Bariatric Surgery
City, State: _________________________________________________ Date of Birth: ____/____ /____
❑ Cardiology
❑ Cardiothoracic Surgery
Parent/Guardian: ____________________________________________________________________
❑ Casey Eye Institute
(Please check preferred contact phone number:)
Specialty: _________________________
❑ Dermatology
Home ____________________
Cell ____________________
Work _____________________
■
■
■
❑ Digestive Health (GI, Hepatology, GI Surgery)
Interpreter needed?
Yes
No If yes, Language: __________________________________________
■
■
❑ Endocrinology*
❑ Family Medicine
Primary Care Provider
________________________________________________
(if different from referring):
❑ General Surgery
❑ Genetic Medicine
This visit is … (mark one):
❑ Hematology & Medical Oncology
Routine: Within 30 days
Semi-Urgent:* Within 2 weeks
❑ Marquam Hill
■
■
❑ Beaverton
Urgent:* Less than 48 hours
■
(For urgent appointments, please call us at 503 494-4567 or 800 245-6478)
❑ Gresham
❑ NW Portland
I am requesting:
❑ consult only ❑ ongoing care ❑ referral requested by my patient
❑ East Portland
❑ Tualatin
Patient’s Medical Issue:
❑ Infectious Disease*
❑ Internal Medicine
ICD-10 code: _______________________________________________________________________
❑ Interventional Radiology
❑ Nephrology and Hypertension
Please tell us what specific medical issue to address at this visit:
❑ Neurology*
❑ Neurosurgery
_________________________________________________________________________________
❑ OB/GYN
_________________________________________________________________________________
❑ Ophthalmology
❑ Oral Surgery and Maxillofacial Surgery
_________________________________________________________________________________
❑ Orthopaedics
❑ Otolaryngology
Information Check Off List: Please attach (where applicable)
❑ Pain Center*
❑ Pediatrics
❑ Progress Notes
❑ Previous work up for these symptoms
❑ Perinatology
❑ Plastic and Reconstructive Surgery
❑ Labs
❑ Pathology
❑ Psychiatry
❑ Imaging, X-rays, MRIs, CT Scans
❑ OB/GYN
❑ Pulmonary Care*
❑ Medication List, Allergies
❑ Other______________________________________________
❑ Radiation Medicine
❑ Rehabilitation Services
❑ Sleep and Mood Disorders
Referring Provider Information
❑ Spine Center
❑ Sports Medicine
Name: __________________________________________ Clinic: ____________________________
❑ Surgical Oncology
❑ Transplant
City, State: __________________________________________ Phone No.: ______________________
❑ Trauma
Fax:______________________ E-mail: _________________________________________________
❑ Urologic Surgery
❑ Vascular Surgery
Office Contact:_____________________________________________________________________ __
❑ Other _________________________
________________________________
* See reverse side for special instructions and
information
Questions about this
❑ Specific physician _________________
referral? Call us at:
• For Radiology, Lab or Echo referral,
503 494-4567
download Physician Order Form –
or 800 245-6478.
Imaging Services at
For more referral forms, please call or go to .
10/15 HCM 1058647
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business